Cemetery - Burial Request Form

2. DECEASED INFORMATION

4. First Name*

5. Last Name*

7. Address1*

9. Address2

11. City*

12. State*

13. Zip*

15. Veteran*
    -- Select One --YesNo

16. Marital Status
    -- Select One --MarriedSingleDivorcedWidow/Widower

17. Date of Birth*
    Date of Birth

18. Date of Death*
    Date of Death

20. Next of Kin First Name*

21. Next of Kin Last Name*

23. Relationship*
    -- Select One --Mother/FatherSon/DaughterSpouseBrother/SisterOther

24. Type Relationship if other

25. Next of Kin Phone No.

29. BURIAL INFORMATION

31. Burial Day*

32. Burial Date*
    Burial Date

33. Burial Time*

35. Burial Space Ownership*
    -- Select One --At NeedPre-need

    If the deceased owns a plot at the Hallandale Beach Cemetery it is a pre-need. If not, it is at-need.

36. Owner's Name and Space Number

38. Burial Type

    1. Single
    2. Double
    3. Baby
    4. Niche
    5. Oversized

39. Burial Fee Weekday (At Need)
    -- Select One --$2,880.44 Res NVet Sgl Spc$3,039.87 Res NVet Ovrzd Spc$2,618.44 Res Vet Sgl Spc$2,777.87 Res Vet Ovrzd Spc$4,418.44 NRes NVet Sgl Spc$4,557.87 NRes NVet Ovrzd Spc$3,964.44 NRes Vet Sgl Spc$4,124.07 NRes Vet Ovrzd Spc$604.10 Infant$1,118.10 Cremation Niche

40. Burial Fee Weekend (At Need)
    -- Select One --$3,461.44 Res NVet Sgl Spc$3,620.87 Res NVet Ovrzd$3,199.44 Res Vet Sgl$3,358.87 Res Vet Ovrzd$5,428.44 NRes NVet Sgl$5,587.87 NRes NVet Ovrzd$4,974.64 NRes Vet Sgl$5,134.07 NRes Vet Ovrzd$1,185.10 Infant$1,118.10 Cremation NicheOther

42. Burial Fee Weeday (Pre Need)
    -- Select One --$1,488.44 Res Vet/NVet Sgl No Vault$1,647.87 Res Vet/NVet Ovrzd No Vault$994.10 Res Vet/NVet Sgl/Ovrzd Vault$1,998.44 NRes Vet/NVet Sgl No Vault$2,157.87 NRes Vet/NVet Ovrzd No Vault$1,504.10 NRes Vet/NVet Sgl/Ovrzd Vault

43. Burial Fees Weekend (Pre-Need)
    -- Select One --$2,069.44 Res Vet/NVet Sgl No Vault$2,228.87 Res Vet/NVet Ovrzd No Vault$1,575.10 Res Vet/NVet Sgl/Ovrzd Vault$3,008.44 NRes Vet/NVet Sgl No Vault$3,167.87 NRes Vet/NVet Ovrzd No Vault$ 2,514.10 NRes Vet/NVet Sgl/Ovrzd Vault

47. Funeral Home Name*

48. Contact Person Name*

50. Phone Number*

51. Email Address*

55. Back-up Documents Needed (Please Check Document Uploaded)

    1. Burial Transit Permit (Required Before burial can be scheduled)
    2. Proof of Residency in the City of Hallandale Beach (Driver's License, Utilitie Bill)
    3. Proof of Veteran Status
    4. Cemetery Plot Deed (for Pre-Need)
    5. Permission to Bury (for Pre-Need)

57. Burial Transit Permit

58. Proof of Residency

59. Proof of Veteran Status

61. Cemetery Plot Deed

62. Permission to Bury

Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

* indicates a required field